K. Sargurunathan v. The Secretary To Govt.
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED : 18.03.2020
CORAM
THE HONOURABLE MRS.JUSTICE J.NISHA BANU K.Sargurunathan .. Petitioner Vs.
1) The Secretary to Government, Government of Tamil Nadu, Finance (Salaries) Department, Fort St.George, Chennai 600 009
2) The District Collector, Theni District.
3) The Joint Director of Medicine & Rural Welfare, Theni District.
4) The District Treasury Officer, Theni District, Theni.
5) The General Manager, United India Insurance Co. Ltd., Cilingi Building, No.134, Greams Road, Chennai 600 006
6) The District Coordinator, United India Insurance Co. Ltd., Theni District.
7) The Assistant Treasury Officer, Sub Treasury, Periyakulam, Theni District.
.. Respondents PRAYER: Writ Petition is filed under Article 226 of the Constitution of India praying for the issuance of a Writ of Certiorarified Mandamus calling for the records relating to the impugned order of the 4th respondent in Na.Ka.No.7427/2019/B1 dated .08.2019 signed on 03.09.2019 and to quash the same and consequently direct the respondents herein to reimburse the medical claim of Rs.68,040/- together with interest at the rate of 7.5% p.a. thereon to the 1/7
petitioner covered by the medical records and medical bills within a reasonable time as may be fixed by this Court. For Petitioner : Mr.K.Appadurai For Respondents 1 to 4 : Mr.M.Karuppasamy Pandian, and 7 Additional Government Pleader.
For Respondent No.5 : Mr.A.Shajahan
O R D E R
This writ petition has been filed for issuance of a Writ of Certiorarified Mandamus seeking to quash the impugned order of the 4th respondent made in Na.Ka.No.7427/2019/B1 dated 08.2019 signed on 03.09.2019 and consequently direct the respondents herein to reimburse the medical claim of Rs.68,040/- together with interest at the rate of 7.5% p.a. thereon to the petitioner covered by the medical records and medical bills.
2.Mr.M.Karuppasamy Pandian, learned Additional Government Pleader takes notice for the respondents 1 to 4 and 7 and Mr.A.Shajahan, learned counsel takes notice for the fifth respondent. By consent of both parties, this Writ Petition is taken up for final disposal at the stage of admission itself. 3.The case of the petitioner is that the petitioner was working as Pre-Vocational Instructor in Vadugapatti Middle School, Periyakulam, Theni District and he retired from service on 21.04.2002. His pension PPO No.C.153568/EDA. During his service, he was a member of Health Fund Scheme formed by the Government and necessary premium has been deducted from his salary every month for the health insurance of himself and his family members.
The Government of Tamil Nadu introduced a Health Fund Scheme for the Government employees to protect their health. In the earlier scheme, the Government directly reimbursed the medical expenses incurred on production of medical bills to the patients of Government employees or their family members. 4.According to the petitioner, the Government, for the sake of convenience, appointed the 5th respondent, which is a private insurance company, as its agent to implement the Health Fund Scheme by entering into an agreement, authorizing the 5th respondent to draw the health fund from the salaries/pension of the Government employees and to deal with the medi-claim of the government employees/pensioners.
By virtue of the same, the 5th respondent has been drawing and collecting health fund from the Government employees in the name of health insurance. The significance and object of the project are no medical expenses need be paid to the hospital by the member of the scheme/government servant during treatment.
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5.It is the further case of the petitioner that in October, 2015, the petitioner suffered serious illness and pain over his head and his wife suffered chest pain. The petitioner was admitted in Meenakshi Hospital, Thanjavur on 09.10.2015 and diagnosis was made as Multiple Dermoid Cyste-Scalp and he underwent surgery on 10.10.2015 and he was discharged on 13.10.2015. Similarly, his wife had also undergone surgery for cancer in her chest. The petitioner incurred a total expenditure of Rs.68,040/-. On 18.11.2015, the petitioner sent necessary application for medical reimbursement. The 4th respondent, vide impugned order, dated -.08.2019, signed on 03.09.2019, rejected the same as not eligible as per the guidelines mentioned in the Government Orders. Aggrieved over the same, the petitioner is before this Court.
6.The learned counsel appearing for the petitioner submitted that the petitioner is entitled for reimbursement of amount, as he is the member of the New Health Insurance Scheme and the amounts are deducting from his pension towards premium. The rejection of the claim of the petitioner is not valid. Hence, he prays to allow this Writ Petition.
7.The learned Government Advocate appearing for the respondents 1 to 4 and 7 as well as the learned counsel appearing for the 5th respondent contended that if the petitioner is aggrieved over the impugned order, he can avail the appeal remedy by filing an appeal before the State Level Committee.
8.Heard the learned counsel appearing for the petitioner, learned Government Advocate appearing for the respondents 1 to 4 and 7 and learned counsel appearing for the 5th respondent and perused the materials available on record.
9.In similar circumstances, this Court on several occasions has held that the claim of reimbursement cannot be rejected on the ground that the claim is not eligible as per relevant Government Orders.
10.In this context, it is relevant to consider the Division Bench Judgment of this Court in W.A(MD)No.1617 of 2018 in State Level Empowered Committee Vs. S.Paramasivam and another reported in (2019) 2 MLJ 1, wherein, the Hon'ble Division Bench has held as follows:
"7. The Hon'ble Supreme Court of India in Shiva Kant Jha -vs- Union of India [2018 (5) MLJ 317], dealing with unfair treatment meted out to several retired Government servants in their old age for medical reimbursement under similar provisions of the Central Government Health Scheme, held in para nos. 13, 14 and 15 as follows:- 3/7
"13. With a view to provide the medical facility to the retired/serving CGHS beneficiaries, the Government has empanelled a large number of hospitals on CGHS panel, however, the rates charged for such facility shall be only at the CGHS rates and, hence, the same are paid as per the procedure. Though the Respondent-State has pleaded that the CGHS has to deal with large number of such retired beneficiaries and if the Petitioner is compensated beyond the policy, it would have large ramification as none would follow the procedure to approach the empanelled hospitals and would rather choose private hospital as per their own free will. It cannot be ignored that such private hospitals raise exorbitant bills subjecting the patient to various tests, procedures and treatment which may not be necessary at all times.
14.It is a settled legal position that the Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Speciality Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment.
Can it be said that taking treatment in Speciality Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the Claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds.
Clearly, in the present case, by taking a very inhuman approach, the officials of the CGHS have denied the grant of medical reimbursement in full to the Petitioner forcing him to approach this Court.
15. This is hardly a satisfactory state of affairs. The relevant authorities are required to be more responsive and cannot in a mechanical manner deprive an employee of his legitimate reimbursement. The Central Government Health Scheme (CGHS) was propounded with a purpose of providing 4/7
health facility scheme to the Central Government employees so that they are not left without medical care after retirement. It was in furtherance of the object of a welfare State, which must provide for such medical care that the scheme was brought in force. In the facts of the present case, it cannot be denied that the Writ Petitioner was admitted in the above said hospitals in emergency conditions. Moreover, the law does not require that prior permission has to be taken in such situation where the survival of the person is the prime consideration. The doctors did his operation and had implemented CRT-D device and have done so as one essential and timely.
Though it is the claim of the Respondent-State that the rates were exorbitant whereas the rates charged for such facility shall be only at the CGHS rates and that too after following a proper procedure given in the Circulars issued on time to time by the concerned Ministry, it also cannot be denied that the Petitioner was taken to hospital under emergency conditions for survival of his life which requirement was above the sanctions and treatment in empanelled hospitals."
8.In this context, it would also be useful to refer to clause 14(4) of the Guidelines for Implementation of New Health Insurance Scheme, 2018, for Pensioners (including Spouse)/Family Pensioners in the Appendix to G.O. Ms. No. 222, Finance (Pension) Department, dated 30.06.2018 issued by the Government of Tamil Nadu, which is extracted below:- "14.(4)In case, a Pensioner/Family Pensioner undergoes emergency treatments/surgeries not covered under this Scheme in either Network Hospital or Non-Network Hospital, no claim can be filed under the Health Insurance Scheme. However, they shall be eligible for claim to the extent permissible under the Tamil Nadu Medical Attendance Rules and the G.O. Ms. No. 1023, Health and Family Welfare Department, dated 17.06.1980.
It may be noted that the Tamil Nadu Medical Attendance Rules requires that treatment in private hospitals should not be resorted to except in case of emergencies. Clause 2(3) of the aforesaid Government Order states that in genuine cases of emergency, the claims will be restricted to the expenditure that would have been incurred had the patient taken treatment in a Government hospital excepting diet charges. For claims under Tamil Nadu Medical Attendance Rules, the Beneficiaries may apply to the authority in the department in which the Government employee last served who is competent to process and forward pension proposal to the Accountant General, Tamil Nadu. The Head of Office shall process the claims and pay the eligible claims under the Tamil Nadu Medical Attendance Rules."
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Though that Governmental Order has been issued after the claim has been made in this case, the aforesaid guidelines, which are based upon the instructions provided in the earlier Government orders and the Tamil Nadu Medical Attendance Rules, are obviously clarificatory in nature and would apply to past cases as well.
9.In the light of this incontrovertible legal position coupled with the facts of this case, we confirm the findings of the Writ Court. However, we are of the considered view that it would suffice to award interest at the rate of 7.5% per annum instead of 9% per annum that had been granted for the delay in medical reimbursement to the Petitioner.
10.In the result, the Writ Appeal is allowed in part and the order dated 27.02.2017 in W.P. (MD) No. 23912 of 2016 is modified to the effect that the competent authority of the Government of Tamil Nadu shall examine the claim made by the Petitioner for medical reimbursement under the Tamil Nadu Medical Attendance Rules and sanction and disburse the eligible amount towards the same along with interest thereon at the rate of 7.5% per annum and file a report of such compliance before Registrar (Judicial) of this Court by 31.01.2019. No costs. Consequently, the connected Miscellaneous Petition is closed".
11.In my considered opinion, the above Judgment is squarely applicable to the facts and circumstances of the present case. Therefore, the respondents 2 and 4 shall examine the claim of the petitioner for medical reimbursement under the Tamil Nadu Medical Attendance Rules and sanction and disburse the eligible amount of Medical reimbursement to the petitioner within a period of twelve weeks from the date of receipt of a copy of this order. 12.With the above directions, this writ petition is disposed of. No costs.
Sd/- Assistant Registrar (A.S) // True Copy // / /2020 Sub Assistant Registrar(CS) smn 6/7
To
1) The Secretary to Government, Government of Tamil Nadu, Finance (Salaries) Department, Fort St.George, Chennai 600 009
2) The District Collector, Theni District.
3) The Joint Director of Medicine & Rural Welfare, Theni District.
4) The District Treasury Officer, Theni District, Theni.
5) The Assistant Treasury Officer, Sub Treasury, Periyakulam, Theni District.
+1 CC to M/s.A.SHAJAHAN, Advocate SR-12217.
+1 CC to M/s.K.APPADURAI, Advocate SR-12224.
+1 CC to The SPL.GP SR-12451.
ORDER MADE IN Dated:
18.03.2020 CS(02.07.2020) 7P 9C 7/7